Nursing Elites

1. A client with atrial fibrillation is prescribed warfarin (Coumadin). The nurse should reinforce which dietary instruction?

• A. Avoid foods high in vitamin K.
• B. Increase intake of dairy products.
• C. Limit intake of foods high in fiber.
• D. Increase protein intake.

Correct answer: A

Rationale: The correct answer is to avoid foods high in vitamin K. Clients taking warfarin (Coumadin) should maintain a consistent intake of vitamin K to keep the medication's effectiveness stable. Foods high in vitamin K, such as leafy greens, can interfere with the anticoagulant effects of warfarin. Therefore, it is crucial for clients to avoid these foods to ensure the therapeutic effects of warfarin. Choices B, C, and D are incorrect because increasing dairy products, limiting fiber intake, or increasing protein intake do not directly impact the effectiveness of warfarin therapy and are not necessary dietary modifications for clients on this medication.

2. The client is taking interferon alfa-2a (Roferon-A) and ribavirin (Virazole) combination therapy for hepatitis C and reports overwhelming feelings of depression. Which action should the nurse implement first?

• A. Recommend mental health counseling.
• B. Review the medication actions and interactions.
• C. Assess the client's daily activity level.
• D. Provide information about a support group.

Correct answer: B

Rationale: The priority action for the nurse is to review the medication actions and interactions. Interferon alfa-2a and ribavirin combination therapy for hepatitis C can lead to neuropsychiatric side effects, including depression. By assessing the medication actions and interactions, the nurse can identify if the depression is a known side effect of the medications, and further intervention or adjustment of the treatment plan may be required to address the client's emotional well-being. Recommending mental health counseling (choice A) may be necessary but should come after ensuring that the depression is not solely caused by medication side effects. Assessing the client's daily activity level (choice C) and providing information about a support group (choice D) are important interventions but addressing the medication's potential contribution to the depression takes precedence.

3. The nurse is caring for a client diagnosed with heart failure who is taking digoxin (Lanoxin). Which sign of digoxin toxicity should the nurse monitor for?

• A. Hypertension
• B. Bradycardia
• C. Hyperglycemia
• D. Insomnia

Correct answer: B

Rationale: The correct answer is B: Bradycardia. Bradycardia is a common sign of digoxin toxicity, as digoxin can cause decreased heart rate. Therefore, monitoring the client for signs of bradycardia is crucial. Choices A, C, and D are incorrect. Hypertension is not typically associated with digoxin toxicity; instead, hypotension may occur. Hyperglycemia is not a common sign of digoxin toxicity. Insomnia is also not a typical sign of digoxin toxicity; instead, some patients may experience visual disturbances, confusion, or other neurological symptoms.

4. The LPN/LVN is collecting data on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain. During the admission, the client reports chest pain. The nurse should immediately ask the client which question?

• A. Are you having any nausea?
• B. Where is the pain located?
• C. Are you allergic to any medications?
• D. Do you have your nitroglycerin with you?

Correct answer: B

Rationale: In a client with angina pectoris, determining the location of chest pain is crucial for assessing the potential severity and cause. This information helps the nurse to further evaluate the nature of the pain and its probable origin, aiding in timely and appropriate interventions. Choices A, C, and D are not as immediately relevant as determining the location of the chest pain when assessing a client with angina pectoris.

5. The client is receiving intravenous heparin for the treatment of a pulmonary embolism. Which medication should the nurse ensure is readily available?

• A. Protamine sulfate
• B. Vitamin K
• C. Calcium gluconate
• D. Magnesium sulfate

Correct answer: A

Rationale: Protamine sulfate is the antidote for heparin, used to reverse its anticoagulant effects. It should be readily available in case of bleeding complications, as it can rapidly neutralize the effects of heparin and prevent excessive bleeding. Vitamin K is used to reverse the effects of warfarin, not heparin (Choice B). Calcium gluconate is used to treat calcium deficiencies, not indicated for heparin therapy (Choice C). Magnesium sulfate is used for conditions like preeclampsia and eclampsia, not for reversing heparin effects (Choice D).

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